A 25-year-old maintenance worker at a steel distribution company
died as the result of a fall from a steel I-beam he had repeatedly
climbed to reach the top of a disabled crane. This worker and
another had been attempting to repair the crane, and had found
it necessary to climb up and down several times for various reasons
(see below). Each time the victim had shimmied down and back
up the I-beam rather than using the fixed ladder some distance
away. When the fall occurred, he was on his way back up and somehow
lost his grip on the beam. Emergency medical assistance was summoned
immediately and the victim was airlifted to a nearby hospital
where he died the following day.

In order to prevent similar incidents, FACE investigators recommend
that employers should:

train employees in the recognition of hazards, and methods
to control such hazards, including the use of appropriate safety
equipment;

ensure that workers continually adhere to the safe work procedures
established by the employer, and actively encourage workers to
participate in workplace safety;

routinely conduct both scheduled and unscheduled safety inspections;

evaluate their current safety program and incorporate specific
training procedures emphasizing the importance of following safety
guidelines; and,

ensure that adequate fall protection equipment is provided
to and used by employees whenever work is performed from an elevation
where the potential for a fall exists;

INTRODUCTION

On May 19, 1996, FACE investigators were informed of the May
17 death of a 25-year-old steel company employee. An investigation
was immediately initiated. Although a site visit was refused
by the company manager (see below), he granted a telephone interview.
Interviews were also held with the Kentucky Occupational Safety
and Health Administration (KY OSHA) safety program manager and
the investigating compliance officer.

The employer in this case is a steel distribution business. The
company receives steel from steel mills and performs some minor
processing, but primarily warehouses and delivers large pieces
of steel ("plates") to manufacturers. Nationwide, the
corporation employs 800 people; 35 work at the site where this
incident occurred. This site is located in a small town, and
many of the workers have been acquainted for years. Because of
the close relationships among many of the employees, the incident
was especially disturbing to them. It was for this reason that
the site visit was denied by the manager.

INVESTIGATION

On the day prior to the incident, the victim had clocked in
at 11:59 a.m. He and another maintenance worker had performed
their routine duties during the afternoon and evening. These
duties included helping to load trucks with a large crane which
runs on a track the length of the building. The crane needed
repair work which could not be performed until after the trucks
were loaded.

After the other workers left (about 2:00 a.m.), the two maintenance
workers, who were lifelong friends, began work on the crane.
Since the hoist was sticking in the up position, they first worked
on the pendent only. After completing and testing this work,
it was determined that the pendent was not the only problem, and
that further work on the crane was required. The two men had
to go to the top of the crane - an area large enough to park a
car, according to the OSHA compliance officer - to gain access
to the crane's electrical control panel. The crane was parked
at the south end of the building, near the maintenance cage where
tools were located, rather than at the north end where a fixed
ladder was located, and where work on the crane was normally performed.
Since the fixed ladder was some distance away and the crane was
now disabled, the two men scaled a steel I-beam to reach the top.

They took some of the crane's wiring apart, memorizing as they
went along how the wires should go back together. However, when
they started rewiring, the next shift of truck drivers began arriving
and one needed help to load his truck. They climbed down and
helped him, and then climbed back up to the top of the crane.
When they again started to rewire the control panel, they realized
that they could not remember the sequence, so it would be necessary
to get the schematics to use as a guide.

This time the victim climbed down alone, leaving his co-worker
on the crane. Several truck drivers saw him shimmy down the I-beam,
and one commented, "Look at that," but none stopped
him because he appeared to do it so easily. When he found the
schematics he called up to his co-worker that there were two sets.
The co-worker advised him to bring both, so he tucked them under
his shirt and began climbing back up. The co-worker reported
that he heard the victim say, "Whoa," and then a thud.
At first he thought it was a joke his friend was playing, but
then he saw that he had fallen to the concrete floor approximately
25 feet below. He yelled for the truck drivers to call 911.
The victim was airlifted to a nearby hospital where he underwent
surgery and was put on life support. The life support mechanisms
were removed the following day, and the victim died.

CAUSE OF DEATH

Cause of death was skull fractures and massive internal injuries.

RECOMMENDATIONS/DISCUSSION

Recommendation #1: Employers should train employees
in the recognition of hazards, and methods to control such hazards,
including the use of appropriate safety equipment.

Discussion: Employers are required by 29 CFR 1910 to instruct
each employee in the recognition and avoidance of unsafe conditions,
and to control or eliminate any hazards or other exposures to
illness or injury. Employers need to provide training that ensures
that employees understand existing hazards and how to properly
protect themselves. In this case, it should have been required
that employees use the fixed ladder to reach the top of the crane,
rather than climbing a nearby I-beam in an attempt to save time.

Recommendation #2: Employers should ensure that workers
continually adhere to the safe work procedures established by
the employer, and actively encourage workers to participate in
workplace safety.

Discussion: The importance of adherence to established
safe work procedures should continually be stressed. In this
case, the victim, in an effort to save time, shimmied up and down
an I-beam rather than using the ladder some distance away. Another
important factor in this case was fatigue - the victim had been
on the job for more than 18 hours when the incident occurred.
"Safe work practices" should include limiting the number
of hours worked by employees.

Discussion: Employers should be aware of any potential
hazards or unsafe work conditions or practices and should take
an active role to eliminate them. Both scheduled and unscheduled
safety inspections should be conducted by a competent person*
to ensure that the workplace is free of hazardous conditions.
In a case such as this one, management could designate one or
more persons to see that safety regulations are followed during
the night shifts. An employee with such authority might be able
to prevent unsafe work practices such as climbing I-beams.

Recommendation #4: Employers should evaluate their current
safety program and incorporate specific training procedures emphasizing
the importance of following safety guidelines.

Discussion: The existence of a safety program is only
the first step in obtaining a viable safety record. In addition
to enforcement, safety programs should be evaluated and training
procedures incorporated which emphasize the importance of recognizing
and avoiding hazards in the workplace, following established safe
work procedures, and wearing appropriate personal protective equipment.

Recommendation #5: Employers should ensure that adequate
fall protection equipment is provided to and used by employees
whenever work is performed from an elevation where the potential
for a fall exists.

Discussion: The use of a "traditional" safety
belt/lanyard combination, as required by 29 CFR 1910, is sometimes
not practical, particularly where worker mobility is required.
Use of a retracting lanyard equipped with a locking device and
attached to a lifeline can provide sufficient mobility in some
instances.

*A "competent person," per OSHA guidelines, is one who
is capable of identifying existing and predictable hazards in
the surroundings or working conditions which are unsanitary, hazardous
or dangerous to employees, and one who has the authority to take
prompt corrective measures to eliminate them.